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Self-binding directives (SBDs) are psychiatric advance directives that include a clause in which mental health service users consent in advance to involuntary hospital admission and treatment under specified conditions. Medical ethicists and legal scholars identified various potential benefits of SBDs but have also raised ethical concerns. Until recently, little was known about the views of stakeholders on the opportunities and challenges of SBDs.
Aims
This article aims to foster an international exchange on SBDs by comparing recent empirical findings on stakeholders’ views on the opportunities and challenges of SBDs from Germany, the Netherlands, and the United Kingdom.
Method
Comparisons between the empirical findings were drawn using a structured expert consensus process.
Results
Findings converged on many points. Perceived opportunities of SBDs include promotion of autonomy, avoidance of personally defined harms, early intervention, reduction of admission duration, improvement of the therapeutic relationship, involvement of persons of trust, avoidance of involuntary hospital admission, addressing trauma, destigmatization of involuntary treatment, increase of professionals’ confidence, and relief for proxy decision-makers. Perceived challenges include lack of awareness and knowledge, lack of support, undue influence, inaccessibility during crisis, lack of cross-agency coordination, problems of interpretation, difficulties in capacity assessment, restricted therapeutic flexibility, scarce resources, disappointment due to noncompliance, and outdated content. Stakeholders tended to focus on practical challenges and did not often raise fundamental ethical concerns.
Conclusions
Stakeholders tend to see the implementation of SBDs as ethically desirable, provided that the associated challenges are addressed.
Lambeth Home Treatment Team (LHTT) provides short-term intensive community psychiatric care to a diverse South London population. The high turnover of patients requires a streamlined process to review and discuss their progress. We aimed to discuss patients in more frequent, targeted and shorter meetings, and to improve continuity of medical care using a ‘named doctor’ system. We assessed impact on length of stay with LHTT, on staff time as well as on both patient and staff satisfaction.
Methods
The system of once-weekly day-long discussions of entire caseload was replaced by twice-weekly discussions of new and concerning patients only. The system of medical reviews was changed from ad hoc to MDT-agreed allocation to a specific doctor for the duration of LHTT stay.
Data on duration of treatment and caseload size were taken from regular LHTT statistical reports. Staff and patient questionnaires assessed impact on satisfaction and time spent in review discussions.
Results
Qualitative reports of staff experience revealed that the new system was felt to provide better continuity of care, better time efficiency (less time spent learning about new patients) and improved learning experiences for doctors in training. Downsides included lack of ‘automatic second opinion’ when a patient was reviewed by a different doctor, felt to be mitigated by more frequent discussions in MDT reviews when needed.
Patient feedback showed no significant change was noted in overall experience of LHTT, although patients were more likely to feel involved in their care (88% said ‘definitely’ compared to 68% before the change).
Time spent discussing patients in clinical review meetings reduced from an average of 38.5 to 28.5 person-hours per week.
Average caseload reduced from 57 to 42. However, duration of treatment increased from 18.8 days to 20.4 days.
Conclusion
The reduction in staff time in reviews suggests that the system had been appropriately streamlined. While caseload size reduced, duration of stay slightly increased, so the new system was not found to have had a significant impact on objective measures of patient care.
Staff feedback was generally favourable, highlighting continuity of care and time efficiency. Patient feedback, while good both before and after our change, suggested a greater feeling of involvement in their care, possibly due to clearer communication and discussion of plan from the start of LHTT care.
Mother and Baby Units (MBUs) are usually preferred by patients and clinicians. Current provision is limited, although expansion is in progress. To ensure successful investment in services, outcome measurement is vital.
Aims
To describe maternal outcomes, mother–infant outcomes and their relationship in one MBU.
Method
Paired maternal Brief Psychiatric Rating Scale (BPRS) scores, Health of the Nation Outcome Scales (HoNOS) scores and Crittenden CARE-Index (CCI) mother–infant interaction data were collected at admission and discharge.
Results
There were significant improvements in BPRS (n = 152), HoNOS (n = 141) and CCI (n = 62) scores across diagnostic groups. Maternal BPRS scores and mother–infant interaction scores were unrelated. Improvement in maternal HoNOS scores was associated with improved maternal sensitivity and reduction in maternal unresponsiveness and infant passiveness.
Conclusions
Positive outcomes were achieved for mothers and babies across all diagnostic groups. Reduction in maternal symptoms, as measured by BPRS, does not necessarily confer improvement in mother–infant interaction. MBU treatment should focus on both maternal symptoms and mother–infant interaction.
Declaration of interest
None.
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